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,o c� SAN JOAQUIN COUNTY ` x ? ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport less than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PAYMENT Please complete the information below and mail with$77.00 fee to: RECEIVED San Joaquin County Environmental Health Department EP 2009 Medical Waste Management PrograN JOAQUIN m 600 East Main Street, Stockton,CA 95202-3029 SAENVIIRONMENT L SP HEALTH DEPARTED 2009 Medical Waste Hauler Information ��sE�TK�ALr��`°a `�� New ❑ Renewal E+�V,ICES 4 Medical Office/Business Name: .3(x h cc) C 10 Medical Office/Business Address: "7 (' (`, S'-mr-c_ CA Zo�6 City State Zip Code Contact Person: S h,e., ® f- Phone Number: Z© Storage Facility Name: S Z-00-q Ul rl Cou>1icA ,,Ck of � Storage Facility Address: o'l O f CA 9S City State Zip Code Permitted Treatment Facility Name: :SV1 _ ViRLMtftCt0A1 ag&t icas 1re,. Permitted Treatment Facility Address: 15 _ (� . 7rX 2- .cam City State Zip Code l_! List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1. Name: 5�1e-_ -0 Co 6-f-n . QtJ Title: D I't¢.� 2. Name: Ro0 r Title: ijume_ 3. Name: Cn t- Title: A)t)t--,- Co©rd;✓tcJ+or I A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical was ecords shall be kept on file at generator's or health care professional's facility. a� Applicant Signature: Date: 1, lL� ✓`�' Title: a r N C P 2 25 DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval:rc� Vt-e.�J� Date: 6/-4o-q Expiration Date: 12-/ ?� /Oj Date Paid: q 12410q Cash o Received By: EHD 45-01 11/19/08 09-16-09 A01 :52 IN